NUR 631 Topic 14 DQ 1

Sample Answer for NUR 631 Topic 14 DQ 1 Included After Question

Answer all of the questions below using the “Discussion Forum Sample” for your discussion response.

History

R.S. is a 38-year-old white male who presents to his PCP after his wife noticed a suspicious looking, dark brown mole in his scalp while giving him a haircut. He was referred to your clinic. He has a history of lipoma over the left ribcage, surgically removed 10 years ago with no recurrence. He reports an episode of major depression with suicidal tendencies 8 years ago, treated successfully with an antidepressant and psychotherapy for 10 weeks with no recurrence.

Review of Systems (ROS)

  • No changes in vision, smell, or hearing.
  • No headaches, cough, fever, chills, night sweats, nausea, or vomiting.
  • No changes in bowel or bladder habits.
  • No fatigue or weakness.

SKIN

  • Fair complexion with multiple scattered nevi on the back.
  • Negative for rashes and other lesions.
  • Warm to the touch and slightly diaphoretic.
  • Normal distribution of body hair.

HEENT

  • 7-mm nodule on the scalp above the right ear, dome-shaped, symmetric, dark brown in color, no variations.
  • PERRLA.
  • EOMI.
  • Funduscopic WNL.
  • Normal sclera.
  • TMs intact.
  • Mucous membranes moist.
  • Throat without lesions, edema, exudates, or erythema.
  • Poor dentition, several fractured teeth.

Biopsy

An excisional biopsy of the mole showed cells consistent with that of nodular melanoma. Tumor thickness was 3.8 mm. Cervical nodes were enlarged and measured 2.3 and 2.7 cm. A CT scan of the thorax was negative. With the exception of questionable shadows in the liver, the abdominal CT scan was also negative. A CT scan of the brain was clearly positive for 3 lesions.

Laboratory Blood Test Results

  • Na = 142 meq/L
  • Cr = 0.6 mg/dL
  • WBC = 7,200/mm3
  • AST = 115 IU/L
  • K = 4.5 meq/L
  • RBC = 5.3 million/mm3
  • ALT = 145 IU/L
  • Hct = 43%
  • Glu, fasting = 103 mg/dL
  • Mg = 2.7 mg/dL
  • HCO3 = 31 meq/L
  • Cl = 103 meq/L
  • Bilirubin, total = 1.7 mg/dL
  • PO4 = 4.4 mg/dL
  • Ca = 10.3 mg/dL
  • BUN = 14 mg/dL
  • Alb = 3.5 g/dL
  • Alk phos = 278 IU/L
  • Plt = 239,000/mm3
  • Hb = 16.3 g/dL

Questions

  1. Why is the lack of clinical manifestations in the ROS above significant?
  2. Based on this rather limited information provided under History, ROS, SKIN, and HEENT above, which subtype of melanoma is most likely?
  3. Are any of the laboratory blood test results above abnormal and, if so, what is suggested by the abnormality?
  4. What is the current probability that this patient will be alive in 10 years?

A Sample Answer For the Assignment: NUR 631 Topic 14 DQ 1

Title: NUR 631 Topic 14 DQ 1

Why is the lack of clinical manifestations in the ROS above significant?

 The lack of clinical manifestations is significant because nodular melanoma is one of the most aggressive forms of skin cancer. It tends to grow quickly and spread downward into the deeper layers of the skin. Nodular melanoma if not detected and treated early will spread to various parts of the body. The lack of symptoms is significant in that by the time it is detected, it has typically spread making it harder to treat. (Patel, 2021). 

Based on this rather limited information provided under History, ROS, SKIN, and HEENT above, which subtype of melanoma is most likely?

Nodular melanoma unlike other types of skin cancer usually begins as a new growth rather than developing from a mole that previously existed. Nodular melanomas have a nodule or dome shaped growth on the skin. Most nodular melanomas appear as blackish-blue, dark brown, or reddish-blue bump. (Patel, 2021). 

Are any of the laboratory blood test results above abnormal and, if so, what is suggested by the abnormality?

Mild to moderately elevated serum aminotransferases, alkaline phosphatase, and bilirubin levels have been associated with hepatic infiltration of malignant melanoma. (Lee, et al., 2022). 

What is the current probability that this patient will be alive in 10 years?

Malignant melanoma has a high mortality rate and the highest potential of dissemination. The 5-year survival rate of patients with metastatic malignant melanoma is between 5 and 19% and is dependent upon the location and number of metastases. Visceral metastases of especially the brain and liver have a less than 10% 5-year survival rate and a median survival below one year in spite of modern treatments (Sandru, et al., 2014). 

Patel, R. (2021). What is nodular melanoma and what does it look like? Retrieved on August 5, 2023, from https://www.healthline.com/health/skin-cancer/nodular-melanoma

Lee, Y., Lee, J., Kim, H., Park, C., Jung, J., Kim, D., Chung, Y., Ryu, H. (2022). Acute liver failure secondary to hepatic infiltration of malignant melanoma. Clinical Endoscopy 55(2), 287-291. https://doi.org/10.59946/ce.2020.272

Sandru, A., Voinea, S., Panaitescu, E., Blidaru, A. (2014). Survival rates of patients with metastatic malignant melanoma. Journal of Medicine and Life, 7(4), 572-576. PMID: 25713625

A Sample Answer For the Assignment: NUR 631 Topic 14 DQ 1

Title: NUR 631 Topic 14 DQ 1

Why is the lack of clinical manifestations in the ROS above significant?

A 38-year-old male presents to the clinic after his wife noticed a suspicious-looking, dark brown mole on his scalp. The patient presents with no other symptoms, all reviews of systems were negative and would appear healthy otherwise. The lack of clinical manifestations in the review of systems above is significant because underlying skin cancer is almost never noticeable through other pathophysiological systems. The patient does not report any changes in vision, sight, smell, nausea, changes in bowel habits, weakness, or fatigue. A thorough skin examination is required to determine the next course of treatment. The color of the nodule, location, texture, size, shape, border, and changes to the nodule must be noted to determine the type of skin lesion that is present (Gruber & Zito, 2023).

Based on this rather limited information provided under History, ROS, SKIN, and HEENT above, which subtype of melanoma is most likely?

Based on the rather limited information provided under the history, review of systems, skin, and HEENT as noted above, the subtype of melanoma that is most likely is a nodular melanoma malignancy. Based on the information provided, the patient has a 7-mm nodule on the scalp above the right ear, dome-shaped, symmetric, and is dark brown in color, this indicates a nodule melanoma. Melanomas harbor the characteristics of brown-to-black lesions that are asymmetrical, have irregular borders, and are more than 6 mm in diameter (Gruber & Zito, 2023). Melanomas usually appear almost anywhere on the body but mainly on the necks, shoulders, hands, and backs of both men and women. Melanomas occur due to chronic sun exposure or artificial UV light, they tend to grow vertically and can penetrate the endothelium of capillaries where they enter the bloodstream and lymphatics, leading to an eventual metastasis (McCance et.al, 2019).

Are any of the laboratory blood test results above abnormal and, if so, what is suggested by the abnormality?

Yes, the patient’s liver panel is abnormal, the AST is 115 (normal is 10-34), the ALT is 145 (normal is 10-130), and the bilirubin total is 1.7 mg/dL (normal is 0-0.8 mg/dL).  The liver lab results are consistent with an abnormal hepatic process and underlying damage. The patient’s abdominal CT scan showed questionable shadows in the liver indicating possible liver damage. The patient’s cervical nodes are also enlarged at 2.3 cm and 2.7 cm, and the CT scan of the brain showed positive for three lesions. Based on the imaging results there is now a concern for metastases.

What is the current probability that this patient will be alive in 10 years?

Unfortunately for this patient, the probability that they will be alive in 10 years is very low, especially with a poor prognosis. Gruber and Zito remind us that melanomas are one of the most aggressive and lethal forms of cancer with surgical excision being the gold standard of treatment if caught early (2023). If melanomas are not caught early, tumors in the late stage lead to a poor prognosis and often require chemotherapy or immunotherapy (2023).  According to McCance et.al, malignant melanomas spread very quickly and may account for a lower than 5 year survival rate (2019).

References:

Gruber P, Zito PM. Skin Cancer. [Updated 2023 May 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441949/

McCance, K. L., Huether, S. E., Brashers, V. L., Rote, N. S. (2019). Pathophysiology: The biologic basis for disease in adults and children (Eighth ed.). Elsevier.